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Who are you, and what is AMSA Code Green?
We are Katherine Middleton and Georgia Behrens, second-year medical students with a passion for the environment and health. With a national team, we run AMSA Code Green, which is AMSA’s climate change and health project. We provide a platform for Australian medical students to respond to our planet’s health emergency – educating, engaging and advocating on the health challenges posed by climate change. In May 2018, we joined the International Federation of Medical Students’ Associations (IFMSA) delegation to the United Nations (UN) Climate Conference in Bonn, Germany. We spent two weeks watching, learning, sightseeing, and doing a bit of casual international environmental activism.

What is the UN Climate Conference?
The UN Climate Conference is an international meeting of diplomats, policy-makers, scientists, academics and non-governmental organisations, all working together to confront the challenges posed by climate change.[1] This meeting occurs every year in Bonn, Germany, and focuses on continual implementation of the Paris Agreement. The Paris Agreement, which came into force in late 2016, unites countries around the world to take action on climate change. 178 countries are currently signed up as parties to the Paris Agreement, and are thus committed to acting for climate change mitigation and adaptation. The Paris Agreement commits nations to actively prevent increases in global temperatures to well below 2oC. The key aim of this year’s UN Climate Conference was to develop the operating manual for the implementation of the Paris Agreement, also known as the “Paris AgreementRulebook”. This rulebook will be a guide for all involved countries as to how they should go about conducting climate change mitigation and adaptation activities in the upcoming years.[2] The rulebook is due to be finalised at the end of 2018 at the 24th Conference of Parties (COP24) in Katowice, Poland. The significance of COP24 has earned its name “Paris 2.0” (COP21 was where the Paris Agreement was signed).

Why do medical students go?
At every UN Climate Conference, hundreds of people from around the world come as “observers” to watch, learn and contribute to the UN Climate process, even though they are not parties to the Paris Agreement. Youth observers (‘YOUNGOs’) are a particularly important group at every conference, as the UN “recognizes the key role that youth play in tackling climate change”.[3] The IFMSA has been sending youth observers to UN Climate Conferences for a number of years. This is because the IFMSA believes that climate change is an immense global health issue, an issue which future medical doctors should be working hard to address as a matter of urgency. The preamble of the Paris Agreement acknowledges “climate change is a common concern of humankind” and states that climate action must respect “obligations on human rights [including] the right to health”.[4] Over the past few years, IFMSA delegates have been working hard at UN Climate Conferences to ensure that parties to the Paris Agreement remember that climate change is a significant health issue. What did we do there? We did so many wonderful things while attending the conference. First and foremost, we had the opportunity to meet amazing people from around the world, all working incredibly hard to fight climate change and ensure the ongoing health of our planet. These included other globally-minded medical students and youth environmental activists from a wide variety of countries. We also had the privilege to interact with representatives from the World Health Organisation (WHO), and the Executive Secretary of the UN’s main climate change organisation, the United Nations Framework Convention on Climate Change (UNFCCC). We sat in on the international negotiation sessions between different countries about the Paris Rulebook, which was an incredible experience. Getting to see how the UN works in reality is a fascinating (if sometimes bewildering) experience. Alongside the negotiations, we were able to attend a range of presentations and workshops that were being run at the conference. This included the WHO’s talk regarding health impacts of air pollution; a legal team aiding a group of Swiss grandparents in their action of suing the government for a lack of action towards climate change; and many presentations addressing the need to empower women and youth to lead the charge on climate activism. Finally, we got involved in a bit of activism to help remind all the delegates of the urgent health issues posed by climate change. In both weeks of the conference, the IFMSA delegation held a little “action” in the main lobby where we dressed up in lab coats, stethoscopes and more. We were extremely appreciative at how well-received we were, and the never-ending interest of others regarding climate change and health.

What did we learn?
There is a tremendous amount of bureaucracy. At first, it seemed a bit overwhelming and sometimes even counterproductive. But as the week progressed, its purpose became evident. The complexity of climate action on a global scale is such that a one-size-fits-all approach to climate mitigation is not feasible. Discussions within the conference were at times tense for this reason. A phrase we heard time and time again was the need for a “just transition” towards a more renewable future. It taught us that at a global level, climate action needs to be well considered and carefully planned, which is the key to the UNFCCC process. Climate action can seem complex in a developed country such as Australia, and global climate action is no different. However, young people are playing a key role in shaping climate action. The voices of YOUNGOs are surprisingly being listened to, especially as the youth are increasingly contributing to UN processes. We also learnt that Pacific nations, in particular Fiji, are leading the way in the climate change conversation. The Fijian COP23 President called for an international dialogue, whereby party delegates and stakeholders levelled to share stories and take stock of collective efforts to achieve targets of Paris Agreement. A Talanoa is a traditional word used in Fiji to describe a process of sharing ideas, skills and experiences through storytelling.[5] We were fortunate enough to join with other YOUNGOs in our own Talanoa, where youth from all around the world shared stories about the following questions with regards to climate change: Where are we? Where do we want to go? How do we get there? From this sharing of stories we came to realise that globally, we are all in a similar place in terms of climate change, but it is manifesting differently across nations. We all think that education, in a way that people can understand and relate to their own lives, is of utmost importance moving forward. However, climate change cannot be approached from only one discipline. It needs to become integrated into all aspects of public policy. These stories from our peers were inspiring and invigorating. We learnt about the current state of affairs around the world, and became hopeful that if we work together we can figure out how to effectively tackle climate change.

As I scrolled through my Facebook News Feed on my millennial pink iPhone, I noticed a bitter tone creeping into my thoughts. A friend was on a European vacation in Santorini. #blessed. Another friend had just completed a marathon run in a personal best time. I’m not sure that I could complete a marathon even if someone carried me to the finish line. Someone else had posted an image of the kale and quinoa power bowl they had consumed for lunch— complete with cold-pressed juice accompaniment— and affectionately captioned it “healthy habits”. Silently stashing away my half-priced, greasy hot chip lunch on a bus most definitely not in Europe, I was overcome with feelings of inadequacy and dissatisfaction. In my mind, none of my achievements or positive attributes could hold a candle to what my peers were accomplishing. It was all too easy to forget the meticulous curation inherent in social media’s highlights reel of life, complete with the option to edit out any pesky sharp edges of reality. I know I’m not alone in having these intrusive thoughts.

As of June 2018, Instagram has one billion monthly active users.[1] Let us pause for a second and consider what this number means. Not one million, but one billion regular users. One billion individuals routinely scrolling through images purposefully presented to make you chuckle, elicit a tear, provide inspiration, or perhaps trigger self-loathing. One billion other individuals also stalking beauty gurus, unintentionally consuming native advertising and living vicariously through celebrities. If my mortifying Emo phase has taught me anything, it’s that adolescence and the turbulent transition to young adulthood represents a critical time of self-discovery and emotional maturation. Amidst continually evolving technological advancement, young adults come of age in an era where communicating and expressing one’s individuality (or lack thereof) on social media platforms is the norm. [2] Young adults represent the highest proportion of social media users, with 92% of Australians aged 16–17 years frequenting social media,[3] compared to only 30% of individuals aged 65 and over.[4] Considering the centrality of social media in establishing connections, shaping self-identity and providing access to a previously unimaginable wealth of knowledge, its ties to psychological health are inextricable. Facebook continues to reign supreme over other user-generated social networking platforms, which include Twitter, Google+, LinkedIn, Pinterest, Instagram and Snapchat.[5] Despite its ubiquity, we remain largely ignorant to the potential mental health ramifications of navigating the social media minefield.[2] The speed of change has only widened the distinct generational gap between the internet-indoctrinated millennials who face the pressures of this novel online world firsthand and the law-enforcers and policymakers attempting to moderate and improve it.

Growing up as a so-called ‘digital native’,[6] my relationship with social media was always slightly dysfunctional (and occasionally bordering on Stockholm Syndrome). Each brief jaunt to a different social networking platform would spark an uncontrollable spiral of comparison, envy and self-loathing. Yet while I could rely on social media to stir up negative emotions within me, it was also an essential channel of communication for group projects, organising events and simply chatting with peers. Try as I might, social media’s utility made it inescapable; the red notification icon acted like a time-bomb, ticking upwards until I surrendered and reopened the apps I had tried so hard to avoid. Indeed, social media has been described by many young adults as more addictive than smoking or alcohol use.[7] In one study involving social media habits,[8] 5% of young adult participants were afflicted by social media addiction, fulfilling at least five of nine DSM-V criterion also used to tentatively diagnose Internet Gaming Disorder.[9] The endless influx of photographic proof that my friends were leading fulfilling, fun-filled lives made my own situation feel mundane. Why was I lounging at home in sweatpants instead of enjoying a night out with friends? I burdened myself with unhealthy expectations of matching what I was observing on social media, lest I fail to live life to its fullest. But achieving this seemed to demand even more attention, more self-critical comparisons, more dedication to the platforms perpetuating this destructive cycle. It didn’t matter that I barely knew these people on my social media—they simply provided a benchmark, however unrealistic, to juxtapose my life against.

This common sentiment, known colloquially as FOMO (Fear Of Missing Out), has alarming associations with lower mood, greater anxiety and feelings of inadequacy, and is strongly linked with higher levels of social media engagement.[10] Body image remains a significant issue for young adults and adolescents, with 9 out of 10 girls citing dissatisfaction regarding their figure.[11] Social media provides an infinite pool of candidates to compare oneself to online, all just a click or tap away. With 80 million photographs uploaded to Instagram daily,[12] young adults are continually bombarded with heavily edited, meticulously staged images presented as if they were “natural”. How often have I found myself subconsciously assessing my worth through superficial, appearance-based comparisons using social media? Far more often than I will ever admit to. Inevitably, this has significant ramifications. Not only has perusing Facebook been linked with higher rates of body image concerns from women and girls, but also an amplified desire for physical appearance changes, which may be associated with the increasing rates of cosmetic surgery in young adults.[2] The mounting pressure to become this ‘perfect’ individual can fuel feelings of inadequacy and low self-esteem, potentially contributing to the rise of anxiety and depression among young adults.[13] In studies by Lin et al. (2015) and Sampasa-Kanyinga & Lewis (2015), youths spending a disproportionate amount of time (>2 hours) on social media platforms were more likely to report poor mental health, psychological distress and suicidal ideation.[14, 15] Researchers have even coined the term ‘Facebook depression’ to describe the growing evidence supporting the association between the unattainable demands of the online world and poor mental health.[16]

My attempted character assassination of social media notwithstanding, the substantial benefits of these novel communication platforms deserve recognition. Social media have presented revolutionary opportunities for young individuals to express themselves and their beliefs. Established in the aftermath of the 2018 Marjory Stoneman Douglas High School shooting, The Never Again MSD Movement’s gun control advocacy is a prime example of social media’s ability to amplify the voices of young adults in a world where attempting to do so by conventional means presents difficulties. For many, social media has revitalized dormant relationships, strengthened existing friendships and helped form online support networks that overcome geographical separation. The ability to connect with like-minded peers and receive emotional support, especially for individuals belonging to real-world minority groups, remains invaluable. Nearly half of all Australians (45%) will experience a mental illness during their lifetime,[17] with prevalence remaining the highest amongst Australian aged 18-24 years (21.2% of all Australians within this age group).[18] Clearly, these are not paltry numbers. While research remains sparse, there is increasing evidence that social media usage may contribute to psychological distress and poorer mental health. Since social media services are not destined for obsolescence anytime soon, a thorough consideration of their lasting psychological impacts grows ever more imperative, especially for young adults and adolescents.

There is No Me Without You: One Woman’s Odyssey to Rescue Africa’s Children.

Melissa Fay Greene’s traveller’s account, There is No Me Without You, is the story of Haregewoin Tefarra, a middle-class Ethiopian widow, who opens up her dwelling as a refuge for hundreds of children orphaned by acquired immunodeficiency syndrome (AIDS). The book presents a stark image of the AIDS crisis in Africa and its decimating effects on Ethiopia. Against prevailing stigmas and the blind eye taken by the international community in its denial of the humanitarian crisis taking place in Ethiopia, Haregewoin’s selfless acts shine as a joyous counterpoint to the bleak reality that continues to consume large parts of Africa.

Greene’s book is an overdue reminder that our humanity is the key ingredient in combating the global fight against AIDS. By illustrating each child’s haunting story of becoming an orphan, Greene not only addresses, but confronts, many paradigms in popular culture. Specifically, she tackles the widespread suggestion that promiscuity and hypersexual behaviours are to blame for the continuation of the AIDS epidemic in Africa. Her stories render this stigma as unfair and over-simplified. Instead, a prevailing feeling of defeat and a distinct lack of alternatives dominate the stories. One woman contracted AIDS from a man who had “lied in saying he would marry her” and fled when he found out she had the disease.[1] The inexorable shame and guilt she felt in bringing a baby into this world without the capacity to support it became a driving factor behind the mother’s decision to abandon the child. Her story is a testament to the helplessness of those under the pressure of extreme marginalisation. Others in the book would come to feel the force of unimaginable accusations and violence after being infected with human immunodeficiency virus (HIV) by a single unsterile injection.[1] Thus, the book exemplifies the dangerous stigma towards those who contract the “unspeakable” disease, and although Greene does not explicitly state it, she certainly alludes to the systemic failure of both domestic and international governments in allowing the crisis to escalate and social stigmas to linger.[1]

Although the social, economic and political insufficiencies of Ethiopian governance are all too obvious throughout the book – for instance, Greene mentions that Ethiopia ranked 170th out of 177 nations for its Human Development Index, and 134th out of 140 nations for its gender inequality-related development index – one cannot help but sympathise with the Ethiopian context.[1] The so-called “free-fall” of health and happiness in Ethiopia is the result of a multiplicity of domestic issues, including border wars, a history of weak and irresponsive leadership, and the lasting effects of colonisation and international oppression. Moreover, the onset of social collapse has been hastened by international politics and imposition. First world trade policies, which forced African countries to assimilate and compete against the global market in the name of “economic modernisation”, with a climate that heavily favoured Western economies, meant that African countries were becoming increasingly dependent on foreign food imports whilst their exports rapidly declined in value. This, in combination with stringent conditions associated with developmental loans, eventually required the slashing of vital public sectors such as health and education as a means of reducing government expenditure.

Despite this, Greene is careful not to lay the blame purely on international delinquency in the domains of political, economic and social governance. She notes that instances of governmental failure and corruption in Ethiopia’s history, including concealment of famine, vastly excessive military expenditure, and ongoing ethnic tensions, have all contributed to the rampant state of HIV/AIDS in Ethiopia. Yet one could argue that by the time the AIDS epidemic had hit Ethiopia, the sustained stagnation of the Ethiopian economy and international impositions had rendered it almost impossible for Ethiopia to properly handle the crisis without international intervention. It follows then, that the AIDS epidemic is a blatant example of deliberate ignorance by the Western world. In a country where two-thirds of school-age children are not in school, only 41% of adults can read, and 81% of people live on less than two dollars a day, the country is simply not equipped with the resources and administration it needs to win the war against AIDS.[1]

Indeed, it could be argued that the delay in the provision of antiretroviral treatments is an issue of international irresponsibility rather than domestic governance. For instance, Greene mentions that the Unites States government stood against mass-producing cheap drugs as a method of protecting the profits of American multinational pharmaceutical corporations. This was done at the expense of some millions of people in Africa dying of AIDS under the illusory pretence of “public health realism”.[1] Without lifesaving antiretroviral treatment, the helplessness and impossibility of resurrecting the AIDS situation is made manifest by the character, Dr Rick Hodes. Although he was an American doctor, he knew that “without the antiretroviral medication, he couldn’t save a single life”.[1] Arguably then, Ethiopians, especially those who contracted HIV, fell victim to misallocated resources and the neglect of the international community.

However, this argument is limited in many ways, a point that Greene is quick to emphasise. In the age of the AIDS pandemic, there were those both within Ethiopia, such as Haregewoin, and those outside the borders of the country, such as Dr. Rick Hodes, who worked tirelessly to suppress the epidemic that had infiltrated the country. More specifically, Greene emphasises families from foreign countries who provided lifelines to orphaned children through adoption. In direct opposition to the widespread negligence of the West in failing to provide lifesaving medication to Ethiopia, the adoption of unwanted, psychologically traumatised, and at times deathly sick orphans by otherwise well-off families is a testament to the fortitude and love of the human spirit. Thus, just as Ethiopia may be considered a victim of international immobility, it was also arguably the recipient of an altruistic salvation by the international community. In conclusion, the book discusses the African AIDS crisis in a powerful yet sensitive manner. Greene does well in addressing the multiple facets of the AIDS pandemic: the relentless social stigmas, lack of treatment options, international neglect and the burgeoning number of families destroyed by the pandemic. Although the book itself brims with grief, it also stands as a testament to what a single human being or family can do for others “in a place with no people”

Acknowledgements
None

Photo credits
There is No Me Without You: One Woman’s Odyssey to Rescue Africa’s Children Melissa Fay Greene]. Bloomsbury USA. 2016 [cited 5 October 2018]. Available from: https://www. bloomsbury.com/uk/there-is-no-me-withoutyou-9781596912939/

Conflicts of interest
None declared

Correspondence
julianaw@student.unimelb.edu.au

References
1. Greene, M. (2006). There is No Me Without You [Book]. New York: Bloomsbury [cited 2018 Sept 17].

Despite what your mother may have told you, it’s not just what’s on the inside that counts. As medical students, our external image matters greatly. We dress to impress, to show patients that we are capable and trustworthy. But how would our patients feel if they knew who made our clothes? Sustainable fashion is by no means a new idea, and most people I know support the idea, yet many of us still wear brands that are known to engage in unethical practices. Although we as medical students generally wish to improve others’ quality of life, too often we put ethics on the backburner as we convince ourselves that we are too busy, too tired, too whatever-it-happens-to-be that day, to think of the consequences of our actions. If we were truly compassionate, it would seem incongruent that we would not also express this in choosing which brands to support.

After becoming increasingly concerned, I discussed the issue with a friend who told me that given the opportunity, most people will choose to do good. That is, most people don’t want to benefit from the exploitation of others but will unthinkingly ignore the reality of how most clothes are made. Every day we are exposed to marketing on billboards, bus stops, shop windows, YouTube, Facebook, fashion blogs, and Instagram feeds. Our first thought is not ‘who made this?’, but ‘I want that’. It’s automatic, and that’s why it works. I choose to believe that my peers are not consciously deciding to fund a harmful industry, and that instead their choices simply reflect a lack of opportunity to consider their purchases. Here is said opportunity. Think carefully and buy ethically, so as to avoid a fashion faux-pas that’s more than just embarrassing— one that results in child slavery, abysmal wages and factory collapses causing thousands of deaths. If you would like to join me in protesting an industry that fuels the maltreatment and exploitation of others, then read on.

This is my manifesto to fashion, and all the illnesses, injuries and deaths that it can cause when not held accountable.

Do no harm

The famous, perhaps trite, Hippocratic oath often comes to mind when considering the part that many medical students have played in the illnesses inflicted on sweatshop workers. It is a turn of phrase strongly associated with the medical profession, and one that most doctors and medical students take very seriously. While much has changed since the oath was created 2,500 years ago, human nature is still very much the same. This oath is important because it sets clear boundaries for minimum decency. To paraphrase Hippocrates, —‘Guys, I know you’re busy and all, but at least don’t give Bangladeshi women gastric ulcers and deprive them of food and sleep for days on end.’ Bangladeshi sweatshop workers receive one of the lowest minimum wages in the world,[1] and women often feel obliged to prostitute themselves at work for extra money.[2] To help understand how severely impoverished they are, let’s take into account their average monthly wage, 3000 taka, which is approximately $50 Australian Dollars. Working 16 hours a day for 7 days a week, they have made the shirt on your back for 10 cents an hour. For an extra 7 cents an hour, they would have enough to meet the “living wage”,[3] defined as “the minimum required to provide a family with shelter, food and education”.[3] If you add on the other burdens associated with sweatshops; the cramped living, lack of maternity care, and risk of silicosis from all the sand blasting so your denim can have that worn aesthetic, Hippocrates would be turning in his grave.[4] No cause justifies the deaths of innocent people Averting the deaths of innocent civilians seems like another no-brainer, but in a globally reported disaster in April 2013, an eight-story sweatshop in Dhaka, Bangladesh, collapsed, killing over a thousand people and injuring over two thousand.[5] The sweatshop supplied clothes to international brands such as Primark and H&M. [5, 6] While this disaster was widely discussed, it is one of many examples of the deaths inflicted on Bangladeshi workers. Another 7 deadly accidents were reported to have occurred in Bangladesh between 2005 and 2015.[7] An example of the response from companies involved is the one provided by H&M after the Rana Plaza collapse. “It is important to remember that this disaster is an infrastructure problem in Bangladesh and not a problem specific to the textile industry”. [8] This response shifts the blame to a poverty-stricken country and should not absolve them from participating in the exploitation of Bangladeshi workers. Although these disasters may seem far away from our comparatively comfortable lives, the deplorable crimes committed by the fashion industry are being committed by the fashion industry in our names. Many of the clothing brands worn by my peers here in Australia have been remonstrated for their manufacture practices, including Tigerlily, UNIQLO, Gorman, Ralph Lauren, Lacoste, Boohoo, and Dotti.[9] Choosing which pretty dress or flash new suit to buy for the next ball can seem like a life or death situation, but instead of only stressing over which looks best, also ask yourself where and how it was made. There are actual lives at stake, not just social ones, and they are lives that you can help to save simply by asking the right questions.

Practice what you preach

Do what your favourite soul singer tells you to do and “Practice What You Preach” (Barry White, 1994). How could you resist that deep baritone anyway? Sustainable fashion is generally seen as an ethical “thumbs up”, and yet so many people don’t practice it. There are a range of reasons that beliefs may not necessarily transfer to action, but the difficulty in keeping track of which brands treat their workers fairly seems to be a key one. One way to combat this challenge is to refer to an organisation that conveniently does it for you, such as Ethical Clothing Australia (ECA), which maps the local supply chain of brands to ensure the fair treatment of clothing workers. It provides a list of those brands which provide fair wages and decent living conditions, and its website lists these brands for your perusal. Some included brands are Cue, Manning Cartell, Thurley, Scanlan Theodore and Nobody.[10] As a general rule, however, it helps to ask if the price tag on an item really reflects the amount of work that went into making it.[11] A Kmart t-shirt‘s $3 price tag may be appealing to some, but their supply chain is untraceable and the workers receive a “minimum wage”, less than a “living wage”, the amount required to meet basic costs of living.[11] When considering price, it is obviously very important to acknowledge that not everyone can afford to pay for organic, handmade clothes. Some ways to overcome this include participating in the events run by charities like Fashion Revolution that work at raising awareness, shopping secondhand so that your money does not go directly to exploitative companies, learning to make your own clothes and writing to companies to put pressure on them to subscribe to ethical practice. [12] Go on, make Barry proud.

There are alternatives to supporting exploitative fashion labels. Protesting the unethical choices of the fashion industry doesn’t mean you have to look like a hessian sack. Fashion is about making you feel like your best self, which is hard to accomplish when your new look endorses an industry that is directly responsible for the illnesses, injuries and deaths of women and children from third world countries. Next time you’re worried about committing a fashion fauxpas at Med Ball, remember your commitment to improving the lives of others. That commitment shouldn’t just remain within the confines of the hospital.

The artificial electrical stimulation of neurons for the treatment of neurological disease and impairment is a well-established field that is undergoing rapid development in the treatment of diseases such as Parkinson’s disease,[1] obsessive compulsive disorder,[2] epilepsy,[3]as well as auditory and visual impairments using cochlear[4] and retinal implants.[5] The basic principle underlying these treatments arises from the inherent electrical excitability of all neurons in the body. By using electrical impulses to stimulate neurons, we can attempt to manipulate their functions. Thus, if there is a dysfunction in the firing of some neurons in the network, we can seek to replace them using electrodes. Generally, this is an area of research only being explored in the context of the developed world, however, particularly in the case of cochlear implants, there may soon be an evolving role for artificial neural stimulation in the developing world.

To appreciate the potential of artificial neural stimulation, we must first appreciate the way in which the neural network operates. The communication between neurons within the brain is the primary control point of all human behaviours, ranging from the movement of our limbs to the control of our deepest thoughts and emotions. These neurons communicate via unique patterns of electrical activity within synchronousneuronal networks, which are composed of billions of cells. Different sensations and behaviours each depend upon a unique subset of neurons within this synchronous network for their function. For instance, the neurons recruited for vision differ in appearance, location, electrical signature, and distribution when compared to those required for hearing. However, when the health of these neurons is compromised, so too is their ability to produce these complex patterns of activity. Artificial neural stimulation takes advantage of the electrical potential of neurons, whose function is dependent upon the flow of charge from one cell to the next. By injecting such neurons with an electrical stimulus using electrodes, we can artificially generate new patterns of neuronal activity that can replace the role of any dysfunctional cells in the network.

Bionic vision is still in its infancy but has made significant strides in the treatment of retinitis pigmentosa, the leading cause of inherited pigmentosa, the leading cause of inherited blindness.[6] There are also plans to utilise it for the treatment of macular degeneration, the leading cause of blindness in the developed world.[7] A United States Food and Drug Administration (FDA) approved model, developed by Second Sight in the USA, has already been implanted in hundreds of patients for the treatment of retinitis pigmentosa,[8] restoring ‘functional vision’ to its recipients.

Functional vision is significantly different from normal vision and relies on ‘phosphenes’ to produce visual percepts of the surrounding world.[9] Phosphenes are ‘spots’ within the visual field that can be perceived as either light or dark, such that a recipient may be able to perceive a horizon, navigate a dining room table, or see obstacles on a street. Phosphene vision is distinct from normal vision, being unable to depict colour or fine detail, as well as being limited by the number of phosphenes that a patient can see. Each phosphene corresponds to an electrode that has been placed on the retina, so with more electrodes, the patient will be able to perceive more sections of the visual field distinctly. However, there are multiple limitations to achieving higher visual acuity with more electrodes within retinal prostheses such that phosphene vision remains ‘functional’ but rudimentary compared to normal human vision. Michael Ibbotson, Director of the National Vision Research Institute and Professor at The University of Melbourne believes that “the sky is the limit” when it comes to the potential of artificial neural stimulation. “Two key factors have driven the rapid expansion of bionics in recent years; the improvement of surgical techniques for implantation and the increased biocompatibility of the materials used. Recent advances have made it possible to both record from and stimulate neurons in different areas of the brain. For instance, we could record sensory neural information from one part of the brain and then feed it back into motor neurons to emulate more natural movements of the body.” “However, in many cases although we do not perfectly replicate the original neural network’s function, there are still significant positive outcomes for patients psychologically to have a lost sense restored.[10, 11] Despite the difficulty inherent in reading a text with bionic vision, patients would prefer to utilise that sense, which otherwise would be lost to them, rather than opt for an easier means of reading such as an audiobook.” What has been restored for these patients is much more than their sight or their hearing, but rather a restoration of their sense of self.[11]

According to Professor Ibbotson, it seems possible that the future of bionics may expand well beyond the medical world, stating that “once it becomes normal within medicine, it would not surprise me if bionics became cosmetic”. As the technology develops and becomes normalised as a treatment for various impairments and diseases, the public may eventually see an opportunity for self-improvement through artificial neural stimulation. For instance, breast implantation was originally developed for mastectomy patients before it became one of the most popular cosmetic surgeries of the modern world. [12] “If it were possible to improve memory function by selectively stimulating memory circuits at particular times, this could dramatically change the way in which students approached education, as well as in the treatment of memory disorders”. Although it seems closer to science fiction than reality, the cosmetic use of artificial neural stimulation, if it were realised, would have the potential to increase the profitability of this technology. If this were the case, it may be possible to fund its use in less developed regions, where it is currently unavailable. The expanding range of pathologies that can be treated by neural stimulation is promising, particularly for the developed world, but its implementation in the developing world is far more complex.[13] There are many obvious hurdles in utilising this technology beyond high-income countries. The first issue is the prioritisation of resources to ensure the greatest possible impact on public health outcomes. There are many other competing health priorities that require attention before advanced interventions to improve neurological health can be implemented.[14, 15] “The cochlear implant appears to be the exception to the rule” according to Professor Ibbotson. Since its initial clinical introduction for patients in 1985, the cochlear implant has undergone significant developments and is now widely utilised in the treatment of hearing impairment, particularly in paediatrics where its impact is more dramatic in younger brains due to increased neuroplasticity. The cochlear implant has also seen recent introductions into low and middle-income countries in South America, Egypt, India and China, where it has faced multiple ethical and practical challenges.[13] However, recent studies have shown that its use can remain cost-effective, even in regions where there is a scarcity of health resources.[13] This is largely due to both the use of low-cost materials and the high health benefit associated with hearing restoration in patients.

The health priorities of patients also need to be aligned with access to neural implants, regardless of the product’s availability. If patients do not feel the need for such health interventions, then such interventions are unlikely to be utilised. For instance, the cochlear implant is still met with some resistance in the deaf community due to the fear of compromising their cultural identity. [16] Visual impairment is one such example where there is a significant variation between the priorities of the developing world and the developed world. In low-income countries, cataracts are the leading cause of blindness, [17] whilst in the developed world, the leading cause of blindness is age-related macular degeneration. [7] Naturally, there is a gap in the prioritisation of treatment availability where surgical intervention is a successful treatment for cataracts but remains difficult to deliver to disadvantaged regions of the world. The treatment of age-related macular degeneration and other degenerative retinal diseases has inspired the development of the bionic eye, but is less likely to be considered a treatment priority for the developing world until it becomes far more affordable. Global health priorities are consistently evolving to reflect the needs of the wider population.

Although it may be in the distant future, the wider utility of artificial neural stimulation will remain unclear until the technology has sufficiently advanced. It will be important for patients to have an awareness and understanding of such technology in the future, so that it is more likely to be accepted as a potential treatment for future health initiatives.

At a recent public forum, Professor Ibbotson also reported that one of the primary concerns of the public surrounding the use of neural implants was the potential for ‘mind control’. This demonstrates a significant gap in the public’s understanding of what artificial neural stimulation aims to achieve, as well as what it is capable of.

The potential for this type of neural control is well beyond the capabilities of current technology, which aims to stimulate otherwise inactive local networks of the brain to restore a lost function such as vision or hearing.[18] However, these patient concerns are still important to consider if such technology is ever to be widely implemented in medicine in the future. The human brain is infinitely complex and research is only recently gaining significant momentum in our understanding of its function.

The development of artificial neural stimulation is an expanding field for the treatment of degenerative neural diseases. Although this technology is in its infancy, it has enormous potential for public health outcomes in both the developed and developing worlds, which are yet to be fully realised. The range of pathologies treated with artificial neural stimulation is expanding as rapidly as our understanding of the brain itself, making the development of this research an important area to watch in the future of medicine.

Aims: To understand: the perception of depression as an illness in South Asia and the language used to describe it, its perceived aetiology, how individuals with depression are perceived by the community and the beliefs in the community surrounding the treatment of depression.

Methods: Articles were found through a database search of MedLine, PSYCINFO, and GoogleScholar. They were included if they discussed depression within the context of a South Asian culture.

Results: Depression is widely understood in South Asia as a disease with primarily somatic presentations stemming from stresses associated with difficult socioeconomic circumstances. Those with depression are often stigmatised but they are generally not excluded from the community. Alongside medical intervention, assistance from family and the community are the most accepted methods of addressing depression.

Conclusions: South Asian perceptions of depression accord with a psychosocial model of illness. Incorporating these perceptions is essential to the success of interventions and educational programs hoping to resonate with a general population and improve communication with health professionals.

Introduction
Depression, suffered by more than 300 million people worldwide, represents the single greatest contributor to global non-fatal health loss.[1, 2, 3] Its impacts are not limited to the Western world. While developed countries draw much of the research focus, the South Asian prevalence of depression was calculated at 26.3% based on primary care presentations.[1] In India in 2004 it accounted for a greater number of disability adjusted life years per 100,000 people than both cancer and diabetes mellitus combined.[1] Depression is particularly under-recognised and undertreated in rural areas.[4] The presentations, sequelae and understandings of depression are known to depend on culture, a relationship maintained in the South Asian context. [5, 6, 7, 8] Existing research highlights significant differences between developed and developing world perspectives on the disease—the extent to which depression is seen as somatic, the role of socioeconomic factors in its aetiology and community responsibilities in addressing it.[4] The strict biomedical conception of depression favoured by some health professionals may translate poorly across cultures and pose obstacles to improving recognition, treatment and education.[9] This paper aims to discuss general perceptions of depression in developing countries in South Asia. It will identify community views on: (1) depression as an illness, including the way it is described and presents; (2) its aetiology; (3) opinions about individuals with depression; and (4) beliefs about treatment. In synthesising the trends and repeating themes revealed by research, it hopes to provide a foundation for tailoring clinical and public health interventions to a South Asian cultural context.

Methods
Articles were found through a database search of MedLine, PSYCINFO, and GoogleScholar using the following keywords and MESH terms: Mental Disorders OR Depression; Developing Countries OR Asia OR Afghanistan OR India OR Sri Lanka OR Nepal OR Bhutan OR Maldives OR Pakistan; and Stigma, Public Perception, Understanding, OR Health Literacy. Studies were excluded if they were not published English language articles relating to depression in South Asian cultures.

Participants generally professed a poor medical understanding of depression and other mental illnesses. Many in the Liu et al. study (42.77%) could not answer what the word ‘depression’ meant to them.[4] In the Indian state of Maharashtra, 87.5% of community members did not acknowledge depression as a real medical illness.[10] However, participant groups frequently employed locally appropriate terminology when presented with a depression case study or vignette. Bangladeshi respondents referred to chinta rog or “worry illness”. [5] The Dari language speaks of asfurgdadi, the low mood and grief associated with hardships.[11] Using tailored vocabulary greatly improved communication between researchers and participants.[5] Both participants with depression and communities in general stressed the physical manifestations of the disease.[4, 5, 6, 9] The most commonly identified somatic symptoms associated with depression included fatigue, pain, numbness, sleeplessness, headache, breathlessness, and shaking.[5, 6, 9, 11] While several psychological symptoms were also listed,[5, 11] the physical aspects of the disease dominated and were often the main reasons to seek help.[6]

Aetiology of depression

An overwhelming majority of study participants described depression through a psychosocial understanding of its origins, emphasising the suffering individual’s social context. In rural Indian villages, depression is seen as an accumulation and escalation of grief or stress.[4] Many studies identified poverty and unemployment as major contributors to these pressures.[5, 6, 9] In Bangladesh it is believed that all tension rogs or “anxiety illnesses” are due to obhab, a (typically material) need of some kind caused by poverty.[5] Culturally specific financial stressors included an inability to provide dowry and education for all of one’s daughters.[5] Other stressors ranged from female reproductive problems and domestic violence to social inequality, injustice, and trauma.[4, 6, 9, 11] Refugees interviewed by Alemi et al. described language difficulties, family separations and cultural clashes.[11] A number of participants attributed depression to religious, supernatural or spiritual factors. A vignette about a woman with depression in Liu et al.’s study prompted participant theories about divine punishment and black magic.[4] Many raised the possibility of spiritual possession.[4] The Liu et al. study was an outlier in terms of biological explanations for aetiology— 54% of respondents linked depression to a disease of the brain and 33.8% believed it was inheritable.[4] The presentation of these options in a questionnaire, as opposed to the open-ended interviews of other studies, may have contributed to this divergence. But some of the external causative factors identified by participants, like “problems in the environment”[6] and polluted air,[4] also hint at a biological understanding of depression’s causes.

Perception of individuals with depression

Expressions of stigma were common. In two of the Indian studies the majority of individuals believed depression is a sign of weakness.[4, 10] In the Kermode et al. study,[10] 40% of community members concurred that people with depression are dangerous, 52.1% said they are erratic and 42.5% believed they should be avoided. Similarly, a large minority of respondents in the Liu et al. study described those with depression as unpredictable (43.8%), hard to talk with (40.5%), and a cause of familial shame (45.1%).[4] Despite this, most individuals expressed a willingness to remain the neighbours, friends and co-workers of someone with depression.[4, 10] These opinions were more likely in respondents who regarded depression as a “sign of weakness” instead of a genetic or biological disease. However, only 60.8% of participants were willing to accept someone with depression marrying into their family.[10] Bangladeshi respondents echoed these doubts about the marriage prospects of people with depression.[5]

Understandings of treatment

Most participants across the studies thought depression would be difficult—if not impossible—to remedy without assistance.[4, 10, 11] Pharmaceutical treatments were often poorly understood and warily regarded. Medication was restricted to treating the physical symptoms of depression.[9] Some participants were concerned about the addictive potential of using drugs to treat depression.[4] In Bangladesh, tablets were the option of last resort, partly due to cost.[5] Bangladeshi respondents instead prioritised poverty alleviation, good health and positive family relations.[5] Opinions of medical practitioners were generally positive. The patients in the Naeem et al. study professed a strong faith in doctors despite minimal awareness of their role in depression management and limited familiarity with non-pharmacological treatments like psychotherapy.[6] Sri Lankan undergraduate students who saw depression as a mental illness had confidence in medical experts[12] and refugees in Afghanistan also expressed faith in psychiatrists.[11] Opinions about traditional and religious healing modalities were mixed across the studies. In India, some respondents reported using herbal medicine to treat depression’s somatic symptoms,[9] and participants from Afghanistan sometimes consulted a tabib or herbal specialist.[11] A minority in the Indian, Bangladeshi, and Afghan samples identified religious practices, mantras and amulets as possible remedies.[5, 9, 11] Conversely, in another study, 63% of participants doubted traditional healers could successfully remedy depression, with more enthusiasm for their effectiveness only in conjunction with medical treatment.[4] None of the participants in the Pakistan study had visited a traditional healer, though one participant did recite passages from the Quran and perform the practice of do dum (or blowing air) on themselves as a form of self-help.[6] Several studies highlighted familial or social support as a particularly popular treatment option.[4, 5, 9] Bangladeshi respondents typically approached family members and close relatives before seeking help from other sources. Many of these individuals believed a community-based program would be the ideal way to address depression.[5] Other suggested treatments included involvement in communal activities,[5, 9] internal dialogue[9] and lifestyle changes such as eating right and exercising.[11] In Alemi et al., cultural activities, such as listening to Afghan music and visiting Afghanistan, were also named.[11]

Discussion

The reviewed literature suggests depression in South Asia is widely understood as a stress-related disease that emerges out of difficult socioeconomic circumstances and has primarily somatic manifestations. While those with depression are still subject to stigma, communal exclusion is rare.[4, 10] Familial and community assistance are the most accepted treatments for depression with medical intervention reserved for physical symptoms. [4, 5] South Asian respondents overwhelmingly favoured a psychosocial model of depression’s aetiology with minimal emphasis on biology. Empathy and understanding seemed highest when causal explanations of depression were linked to relatable hardships. Education campaigns and anti-stigma efforts may have more success if framed through this understanding of the disease compared to approaches rooted in biomedicine. In Kermode et al., individuals who related depression to a personal flaw (“weakness”) or extrinsic factors (e.g., family and financial problems) were less likely to socially distance themselves from people with depression compared to those who believed in a biological cause.[10] Biology may be seen to imply a lack of agency and the possibility of hereditary transmission, both of which negatively impact marriage prospects. This aetiological understanding of depression affects the acceptance of pharmacological interventions. While Indian respondents used pharmacological treatments for somatic symptoms, and drugs are seen as a valid last resort in Bangladesh,[5] the expense and arcane mechanisms of action of antidepressants may compromise adherence when they are prescribed. Nonpharmacological methods might be more acceptable despite remaining mostly unheard of in more rural areas. A study on university students in Pakistan, for example, found that cognitive behavioural therapy could be successful in that population provided interventions are tailored to South Asian cultural and religious values.[13] As depression is commonly attributed to external socioeconomic factors, programs addressing these wider social issues may reduce its prevalence. Studies investigating poverty alleviation as an intervention for depression have reported conflicting results in Uganda and Mexico.[14, 15] The evidence suggests depression interventions demand a multi-faceted approach. The importance of family and the community support for individuals with depression was a motif across the reviewed studies. South Asian countries are characterised by collectivistic cultures emphasising close family ties.[16] While family and the community participation in interventions can be extremely beneficial, the isolation and interpersonal conflict associated with stigma can be especially damaging. Community-based interventions were the ideal approach for participants in the Selim et al. study.[5] Education campaigns targeting the family and communities around individuals with depression may be fruitful.

Limitations

Due to the limited body of research on this topic as it relates to this region, not every South Asian country could be represented in this review. The included studies cannot be interpreted as reflecting universally held beliefs within their respective countries. The review also only included English-language studies, narrowing its scope further and perhaps excluding significant contributions from local research. It is possible participants were reluctant to openly share their traditional and religious beliefs with medical professionals or as part of a scientific study, resulting in their underrepresentation.[6]

Conclusion

This review aimed to present a general overview of how depression is perceived in the developing countries of South Asia. Considering these synthesised findings may help shape future public health efforts seeking greater success in improving education about depression and its treatment and prevention—in South Asia, and potentially in other developing countries where depression is similarly understood.

The number of clinical trials conducted in developing countries has increased dramatically in recent decades due to globalisation and increased need for trial subjects. For example, between 2002 and 2007 the number of United States (US) sponsors conducting pharmaceutical research abroad increased by 15% annually, while US-based trials decreased by 5.5%.[1] All trials involving human subjects require ethical discussion, and this is of particular importance in developing nations, where risk of exploitation is high. In this article I will describe the legislation surrounding these trials, summarise the benefits of clinical trials to developing nations and researchers, analyse the ethical issues raised by this practice through a principles-based and utilitarian lens, and discuss how future legislation could align the potential benefits of these trials with reality.

Legislation surrounding clinical trials

To understand why clinical trials in developing countries are conducive to exploitation, the issues with the legislation in place must first be understood.

International

Numerous international bodies have created documents outlining clinical trial guidelines. One of the most commonly referenced documents is the Declaration of Helsinki (DoH), developed and regularly updated by the World Medical Association. International guidelines such as this are not legally binding, but are referred to in the legislation of many countries.[2] These international guidelines have been criticised for being vague and thereby allowing researchers to circumvent their recommendations.[3] For example, the DoH states that new interventions must be tested against the current best intervention, that researchers should make provisions for post-trial access to their intervention, and that medical research on a group is only justified if it is responsive to their health needs.[4] However, the DoH lists circumstances in which placebo use is acceptable, does not specify the duration of availability or price of the intervention post-trial, and does not define how significant a health need must be for a community to justify participation in a trial.

Developed nations

Developed nations have regulations to protect subjects in trials within their country that are enforced by ethics committees. However, depending on who is funding the research, such regulations do not always have to be followed regulations do not always have to be followed when conducting research internationally.[5] It can also be problematic to apply laws from one culture to another. For example, in the US, sponsors do not have to compensate subjects for treatment of research-related injuries, but this cannot reasonably be applied to nations where subjects cannot afford treatment.[6]

Developing nations

Developing nations are less likely to have established and financially-supported clinical trial regulation, and the increase in clinical trials in developing nations in recent years has overwhelmed existing ethical review systems.[7] This makes it easy for researchers to avoid investigation, and a 2004 study found that 44% of studies in developing nations did not undergo any review from the country in which they took place.[8]

Arguments for clinical trials in developing countries

For companies

The advantages for companies of conducting clinical trials in developing countries are numerous. Costs are significantly reduced as a result of lower salaries, cheaper facilities, and less time being required to receive approval for a trial. [9] Participant recruitment is also easier, due to the higher prevalence of diseases and paucity of treatment options.[10] Finally, subjects are less likely to have received prior treatment, increasing result significance.[2]

For communities

While it can be easy to assume that clinical trials in developing nations are inherently exploitative, these trials are not without their benefits to local communities. Trials provide pharmaceuticals to people who may otherwise have extremely limited access, and if the recommendations made in the DoH are implemented, these communities may have continued access to the drugs being tested.[11] Furthermore, through conducting clinical trials, researchers can provide equipment and knowledge to advance local research, and can boost local economies.[12]

Ethical perspectives

If research is conducted ethically and following international guidelines, it is possible for all of the benefits described above to be realised. However, as long as clinical trials in developing countries are not properly policed, there are ethical issues implicit in this practice and a risk of exploitation. While there are countless ethical issues to be considered in this area, I will focus on the issues of informed consent, the dangers of trials, placebo use, testing of interventions that target health needs, and post-trial availability of interventions. These will be analysed using a principles based and a utilitarian lens.

Autonomy

Autonomy describes a state in which individuals are free to make their own decisions; one consequence of the principle of autonomy is informed consent. To make decisions, people must be provided with the relevant information in a form they can understand.[13] Informed consent has particular relevance for trials in developing nations, because gaining consent requires understanding local languages and analogies, and obtaining written consent can be difficult in the context of low education rates.[14,15] Additionally, in many communities it is essential to also obtain consent from elders, religious leaders, or heads of families. [16] Thus, in order for clinical trials in developing countries to be considered ethical from the perspective of autonomy, researchers must show cultural awareness in acquiring informed consent.

Beneficence and non-maleficence

Non-maleficence is the principle that actions should not expose individuals to unnecessary harm, while beneficence describes acting in a manner that benefits others.[13] In any clinical trial there is potential for significant harm to come to study subjects. This is particularly true when clinical trials are poorly regulated. For example, up to 2,644 people died in clinical trials of 475 new drugs over a 7-year period in India, with the majority of these trials being conducted by international sponsors.[17] In the context of murky international legislation and the potential for negligent trial structure and administration, such deaths can be considered a violation of the principle of non-maleficence by the researchers. Conversely, clinical trials can also be a force for beneficence in developing nations through the provision of medication and research infrastructure, as previously described. It is thus important that the potential harms and benefits of any trial to a community be carefully considered in order to maximise both principles of beneficence and non-maleficence. A further ethical issue relating to beneficence and non-maleficence is the use of placebos in clinical trials, a pertinent case study being the 1994 African Zidovudine trials. These trials tested Zidovudine as a means of preventing vertical transmission of HIV, with comparison to control groups who received a placebo.[18] During the trial, many women in the control group transmitted HIV to their offspring. This violates the principle of beneficence, as researchers did not act to benefit all trial subjects (which could have been achieved by giving the control group an existing intervention). Whether or not this violates the principle of non-maleficence depends on how harm is defined. If harm requires an individual to be worse-off relative to a baseline, then this placebo use could be considered ethical in a nation where women otherwise receive no treatment.[10,19] However, this creates a double standard for developing countries, as using a placebo when there is existing treatment would be unethical in developed nations, as per recommendations established in the DoH. Views on placebos from this perspective, therefore, may vary.

Justice

The principle of justice involves fair distribution of scarce resources and respect for personal rights and laws.[20] Trials in developing countries are often for ailments primarily affecting developed nations, such as overactive bladder and allergic rhinitis, rather than for diseases that disproportionately affect developing countries.[1] People in developing nations are therefore assuming the risks of research while receiving little benefit. This practice is possible because there are many health needs in developing nations and, as previously stated, the DoH does not specify how important a health need must be for it to be an appropriate research target.[21] From a justice perspective, in order for a trial to be ethical it should target a health priority, not just a health issue present in a community. If this principle is followed, clinical trials may become a means of combatting global healthcare inequalities; indeed, as it stands today, 90% of the global healthcare budget targets illnesses responsible for only 10% of the global disease burden.[22] Another issue pertaining to the principle of justice is continued access to interventions post-trial. Basic medications are often absent or expensive in developing countries; therefore, continuing to offer treatments after a trial ends is one way of fighting this distributive injustice, especially if the intervention is offered to a wider community and the researchers are allied with broader access programmes.[11]

Utilitarianism

Utilitarianism deems actions good if such actions maximise the amount of good for a maximum number of people.[13] Using a utilitarian lens, it can be argued that since clinical trials in developing countries are mutually beneficial, imposing further constraints is not justified.[23] For example, if placebo use was not permitted in the African Zidovudine trials, the trial may not have been conducted, meaning no one would receive treatment. In the context of extreme utilitarianism, it can even be argued that all clinical trials in developing countries are ethically justifiable because the results can potentially help many more people than might be harmed in the trial process. Utilitarianism thus provides a very different overall view of clinical trials in developing countries than a principles-based perspective. In practice, the views of most ethical theorists and international guidelines align with a principles-based perspective, while some developed nations follow the utilitarian perspective and favour scientific arguments and economic advantages over ethical concerns for people in developing countries.[24]

Proposed future changes

It is evident that the current guidelines and legislation surrounding international clinical trials are inadequate to protect trial subjects from exploitation. Because of deficiencies in international legal capacity and infrastructure in developing nations, the responsibility for protecting subjects of clinical trials in developing countries must fall to developed nations. Examples of beneficial changes to current legislation include adjusting laws to be culturally appropriate for developing communities,[24] enforcing governments to commit a portion of tax revenue to research that is responsive to the health priorities of developing countries,[21] and having governments provide incentives to support health policy improvement and appropriate research practices in developing nations.[25] However, such legislation is far from being realised, and is unlikely to be implemented provided that current legislation remains beneficial to developed nations and wealthy researchers.

Conclusion

There are many layers of legislation to be considered when conducting a clinical trial in a developing nation, with considerable potential for contradiction or legislative gaps. Trials can therefore result in exploitation, and require numerous ethical issues to be considered. Exploring these issues using a principles-based perspective reinforces the need for improved legislation surrounding trials; conversely, however, purely utilitarian perspectives support maintenance of the current status quo. While legislation is unlikely to change dramatically in the near future, many ethicists agree that if developed countries improve their legislation, clinical trials in developing nations can become a part of the solution to global health inequality, rather than part of the problem.

Promoting health equity or economic competitiveness?

Bull World Health Organ. 2012;90(1):55-62

Aims: This review aims to summarise the research exploring the health effects of internet pornography

on its users. It focuses on pornography’s addictive potential, impact on sexual behaviours and mental

health.

Methods: The relevant literature concerning the health effects of internet pornography was reviewed.

Resources were sourced from databases such as PubMed and JSTOR.

Results: This review finds significant evidence for the addictive potential of pornography, validating

the consideration of pornography addiction as a clinical diagnosis. Pornography may also cultivate

misogynistic beliefs, affect the sexual functioning of its users and have some role in promoting sexually

aggressive behaviours. Poor mental health and pornography appear to have a bi-directional association.

Conclusions: The potential health effects of pornography are extensive and well-established. Given

the ubiquitous nature of this media, there may be significant clinical implications for these findings.

Background

The proliferation of the Internet has fostered a wild-fire growth of the pornography industry.[1] Pornography is more accessible and widely disseminated than ever before, accounting for a quarter of all internet searches and 1.5% of all websites.[2] However, this growth doesn’t come without concern. The cultivation of sexual abuse, misogyny and poor mental health are among some of the startling accusations made against this industry. [1,3,4] Given that 84% of Australian males and 23% of females aged 16-25 years use this media daily or weekly,[5] if these accusations hold water, they may have significant and widespread impacts. The following review aims to summarise the research on the health effects of pornography on its users.

Compulsive pornography use and addiction

There is considerable debate as to whether pornography has addictive potential and if it does, whether it is comparable to those of other addiction disorders (e.g. alcoholism, compulsive gambling). [6] These well-established addiction disorders are characterised by several common thought and behavioural patterns. These include but are not limited to: (a) perceived lack of control over the substance/ object of abuse; (b) adverse consequences from is use (e.g. relationship, social, work or school problems); (c) an inability to stop its use despite these negative consequences; and (d) preoccupation with the substance/ object of abuse.[7] These symptoms are being increasingly reported in patients who complain of pornography overuse. [6]

Pornography addiction is not at present a formally recognised clinical disorder in the DSM-V or ICD-10, however, the prevalence of these findings has led to the widespread use of Compulsive Pornography Use as a working clinical diagnosis. Many of the studies mentioned in this paper have recruited patients suspected to have this disorder. There is no consensus on the definition of this disorder, but as with other addictions, the aforementioned thought patterns are characteristic[7]. The prevailing argument contesting the recognition of Compulsive Pornography Use as a clinical disorder is the thought that these symptoms reflect a high sex drive in certain populations and are not suggestive of a pathological addiction.[8] Due to this debate, researchers have attempted to draw direct comparisons between those with suspected Compulsive Pornography Use and those with addiction to substances where the disorder is better defined and established (e.g. alcohol). One of the hallmarks of a substance use disorder is an increased desire for a substance without proportional pleasure from its use.[6] On fMRI neuroimaging this can be visualised as decreased striatal responsiveness to dopamine as the brain becomes tolerant to its effects.[9] Very similar findings have been found in patients with suspected pornography addiction. Their desire for this media far exceeds the pleasurable effects it has on them[10] and fMRI changes resemble those in patients with other substance use disorders.[11] Studies have found reduced grey matter volume in the right caudate and dampened putamen activation in those who compulsively use pornography.[12] These patients are also likely to have escalating levels of pornography usage, which supports the theory that a tolerance to pornography can develop.[13]

A predominant counter to these findings is that reduced striatal volume is a precondition for, not a result of increased pornography use.[12] This model argues that people with naturally lowered striatal volume require additional stimuli for dopaminergic responses. They are therefore more likely to consume large amounts of pornography. With this model, those with decreased striatal volume should be able to achieve the full pleasurable effects of pornography, even if more of it is needed.[12] However, there does not seem to be this expected positive dose-effect relationship between pornography use and pleasure.[10] Additionally, laboratory fMRI studies have shown that repeated viewing of sexual images can cause a down-regulation of the brain’s reward pathways.[14] This suggests pornography can play an active role in down-regulating the striatum. The dose-response relationship of this finding is yet to be established, and it remains unclear whether these findings are exclusive to high-volume users or those with other risk factors for addiction.

Gender roles and sexual behaviour

Another charge made against pornography is its potential to promote misogynistic attitudes and behaviours, particularly in males. In a review of 135 studies on the topic, it was found that sexualised media, of which pornography was included, was directly associated with “sexist beliefs … and greater tolerance of sexual violence toward women” in males. [15] This media may play a role in cultivating views that support female objectification, patriarchal ideologies and permissiveness towards female harassment. [1] This association is greatest when pornography is accessed during early adolescence (12-14 years). [16] Longitudinal research in this area is lacking, therefore these findings may simply suggest that people with these views consume greater amounts of pornography as it reaffirms their beliefs. Additionally, if pornography is to have a role in promoting sexist attitudes, the extent to which these opinions go on to influence interactions with others is unclear and difficult to determine.

The research attempting to establish the impact of pornography on sexual encounters is highly conflicted. A prevalent thought is that the violence depicted in its material desensitises viewers to sexual assault, increasing their propensity to commit sexual crimes. [17] This view is supported by findings that porn can increase acceptance of rape and sexual assault in males.[3,18] This influence on sexual violence seems to be greatest and perhaps limited to males with other risk factors for sexually aggressive behaviour. [1] These include: a history of family violence, a cultural upbringing promoting male dominance and toughness, attitudes accepting of violence and impersonal views of sex.[19] Pornography use in these high-risk individuals has been associated with an increased prevalence of forced vaginal, oral and digital penetration, sexually aggressive remarks and sex with animals.[1] This research challenges the argument of a cathartic role for pornography – that its usage can reduce the prevalence of sexual crimes committed in males as these sexual impulses are somewhat acted upon through pornography usage. The active role of pornography usage in promoting sexual assault is well-established in people with other risk factors for sexual assault, however, the causal link between pornography and sexual assault in most users is less strongly established and highly debated.[20] Therefore, pornography may play a role in fostering and validating attitudes that predispose some men to rape women, however, it may have little to no impact in males with no other risk factors for sexually aggressive behaviour.[1] There are many barriers to research into this question, not least the underreporting of sexual assault and the ubiquitous nature of this media.

While pornography may have a limited role in promoting sexually aggressive behaviour in most men, lowered libido and erectile dysfunction are widespread in pornography users.[21] In a study of adolescent males, 16% of those who consumed pornography more than once weekly reported low sexual desire, compared to 0% of those who did not.[22] Other sexual performance problems associated with pornography use include difficulty orgasming, decreased enjoyment of sexual intimacy, less sexual and relationship satisfaction and a preference for pornography over a sexual partner. c [23] Erectile dysfunction is also strongly associated with pornography use and when present, often occurs during intimate sexual relationships, but not to sexually explicit material.[10] Males who use pornography to stimulate sexual desire likely partially account for these findings. However, cessation of pornography use has on numerous accounts been recorded as an effective treatment for patients with sexual dysfunction, suggesting it does also play a causal role in this condition.[24,25] One longitudinal study has also found that pornography usage has a statistically significant role in predicting poor marital quality. Pornography usage was found not only to be a product of marital dissatisfaction, but a causal factor for such dissatisfaction. This media was the second greatest predictor of poor marital quality in the study, following only marital quality at the commencement of the study. These effects increase with frequency of pornography use and seemed to only apply to husbands who use pornography and not to wives. [26]

Mental health

With our society’s increasing interest in mental health, pornography’s impact in this area is beingheavily researched. Pornography usage is strongly associated with mental health disorders, loneliness, poor self-esteem and reduced quality of life. [5,27,28,29] An Australian study of 914 adolescents found that those who reported mental health problems in the last 6 months were 52% more likely to watch pornography at least once weekly than those who did not.[5] Masturbation to internet pornography has also been strongly associated with dissatisfaction in offline life and feelings of poor social support.[29] Pornography may play a causal role in this relationship, but equally, it may be a means by which adolescents aim to aid feelings of loneliness. Exploring the causal nature of this relationship, a study published earlier this year found that intentional exposure to pornography in adolescence was a predictive factor for depression and low self-esteem in later life.[30] On the other hand, a longitudinal study has also found that low self-esteem and depressive feelings in adolescent males are predictive of compulsive pornography use.[31] The extent to which poor mental health and pornography encourage each other is unclear. The increasing ubiquity of this media makes controlled longitudinal trials in this field difficult to conduct. Additional research exploring the therapeutic benefits of pornography cessation in patients with mental health disorders would be of great clinical benefit.

Conclusion

While much of the research exploring the health impacts of pornography is still inconclusive, there is still substantial and warranted concern surrounding this media. This field would greatly benefit from additional longitudinal studies which further clarify the causal role of pornography in promoting the health issues addressed above. The prolific use of this media does serve as a barrier to controlled studies in this field, but also stresses the need for further research, given the extensive clinical implications such findings may have. Additionally, this industry has transformed substantially this century with the proliferation of the internet, and the full impacts of this may yet be apparent.

Interest Predict Symptoms of Compulsive Use of Sexually Explicit

Internet Material Among Adolescent Boys. Journal of Youth and

Adolescence. 2015;45(1):73-84.

Professor Barry Marshall is an Australian Nobel Prize Laureate in the field of gastroenterology and microbiology. Early in his career, Professor Marshall went into internal medicine with a gastrointestinal emphasis, working with Dr J. Robin Warren to demonstrate that Helicobacter pylori is the cause of most peptic ulcers. In this conversation, Professor Marshall describes drinking a dose of the bacteria himself in order to prove causation amongst risk taking in medicine as well as future directions in his field.

I’d like to talk about the very famous story of how you drank a Petri dish containing cultured Helicobacter pylori to make the causal connection of the bacteria with peptic ulcers. Considering the resistance your findings faced by the medical and scientific community, what do you think the reasons were that people were unwilling to consider the connection? For example, do you think there was an economic motive?

What triggered me to do that experiment was a grand round that I did at Fremantle hospital, when I was a medical registrar there. I was in the senior registrar job in internal medicine, so I did a grand round about this bacterium. It became evident that normal non-specialists were just so entrenched with this stress idea – the brain/gut axis. I don’t believe in any of that. They were so entrenched; it was exactly like a religion at that point. You couldn’t move stuff that people knew. Even if you had facts, they just didn’t feel it was right. So the fallback position for everybody was ‘there’s only one person, there must be something he’s doing wrong, otherwise how come it’s not been discovered before?’. So there was that attitude, then the pathologist got up and said ‘well these changes in gastritis are extremely subtle, how can you really measure them objectively? Obviously people with ulcers have got a hole in their stomach and other bacteria can come and live in the ulcer, it’s probably just commensals, you’ve got a long way to go, where’s your animal model?’

At that point, I had been trying to infect rats and mice, guinea pigs and piglets for about six months and getting nowhere. It was kind of frustrating – I had no answer for that. I could not really do the next step. However, I did submit an MD thesis proposal and in that I said that if the animal work fails, then we would try to get a human volunteer experiment. So I had decided that I needed to go to that step. Looking back on it, it was riskier than I originally thought it was because I was pretty certain that I could eradicate it with antibiotics, but the ones I chose in fact probably wouldn’t have worked. I had an endoscopy to make sure I didn’t already have H. pylori. So I drank the bug thinking that I would just be asymptomatic. Most people I knew with H. pylori were infected blood donors. I found 40% of blood donors at Fremantle were infected and didn’t even know they had it. So obviously, it wasn’t killing them and no one could remember where they caught it from. There was no history involved with the infection so it was a bit of a puzzle.

Even Dr. Warren and a couple of other people thought it might have been sexually transmitted, close contact with somebody, because ladies who attended the STD clinic were more likely to be infected than everybody else. There were a whole slough of crazy little pilot studies trying to sort the epidemiology out, it was very confusing. However, I drank the bug and I did become unwell with a vomiting illness and there was no acid in the vomit. That triggered something that I had read in an old medical textbook, The Principles and Practices of Medicine by Sir William Osler in 1910. They described exactly the acute illness that I had. I suddenly realized that these old descriptions of vomiting without any acid in the vomit were probably H. pylori and it became less common and people forgot about it.

Putting it all together at that point, the endoscopy showed a very heavy infection with H. pylori, so it was lucky that I had chosen that strain because I could have chosen one that didn’t infect very well. However, I didn’t get an ulcer and the illness got better after two weeks – it was all over. Discussing it with a few colleagues enabled me to do this hypothesis article for the Medical Journal of Australia. I believe it is either the second or third most cited article in MJA with thousands of citations.

What changes occurred in your life after receiving the Nobel Prize?

I believe Nobel laureates develop a bit of an inferiority complex and maybe some paranoia. One of the things is that I’m always talking about things I know, I’m the font of knowledge for Helicobacter and I keep up in that field, but there are so many other topics that I don’t keep up with. If I pick up the Medical Journal of Australia, I’ll look at the headlines and think that I don’t have time to read certain articles. Similarly, I’m not going to have time to be able to read the journals that I used to read, so I get a bit paranoid about not keeping up.

The other thing is that you’re worried that you don’t have peer review as a Nobel laureate. If you say something, someone is happy to print it or put it up on the web. If I twitter about something and say “this is a load of rubbish” about the microbiome of the stomach, nobody else is saying that. So I think, am I nuts? I’m just looking for a little niche where I can fight the consensus. Anybody who says something is a consensus, I am immediately totally suspicious of it.

Moving on to some of your current research, increasing antibiotic resistance accounts for 15% of patients who are not cured of their H. pylori infections. When these patients are referred to you, you isolate their strain, they receive a ‘tailor-made’ combination of antibiotics. I was hoping you could discuss how much of a threat you believe antibiotic resistance is with respect to H. pylori?

It’s a moderate threat, once you know how to get around it. You learn these principles of microbial therapy in medical school and it’s not going to change. Always, if you find the resistance pattern of the organism, you navigate around it with your antibiotics. The tricky part is that many of the antibiotics I like to use are active in the stomach and are often old. The best example is tetracycline. Everyone says “don’t use that, it’s not very well absorbed, it stays there in the lumen of the gut, it passes out in the stool.” Hang on a minute – that’s great for H. pylori.

There is need for further studies to work out the pharmacology of antibiotics in the gastric mucosa because when amoxicillin fails, we have no idea why it fails. All Helicobacter are always sensitive to amoxicillin. So you should be able to just give people amoxicillin and a PPI (proton pump inhibitor), and expect a cure. We’re not seeing that. So you have to add the third drug, there are different ones.

So I’m not too worried about it with Helicobacter, it’s a bit like a Streptococcus. It’s got a limited repertoire. However, it mutates extremely fast. It’s almost like a virus. According to a paper we did, its right on the top of the list for mutation. The reason is because it doesn’t have to protect its genome. There’s nothing else floating around much except other Helicobacters. So they’re all moving genes around, sucking them in and out as they divide. It doesn’t check the accuracy of its copying. So it’s continuously disabling its ribosomes or changing its ribosomes, so it very easily becomes resistant to macrolides or metronidazole. So it becomes interesting; there’s so many Helicobacter in your stomach – 1010 organisms. So for the stomach, it doesn’t matter that its doing bad copies of itself because it will just continue to have an evolution in the gastric mucosa. That’s why it becomes resistant to these things that require some interaction between an antibiotic and a functional protein, because they disable the protein in some way and then it’s resistant. So I think in the future, we need to do more studies on the pharmacology of the gastric mucosa and immunology. I’m optimistic that we’ll figure it out eventually. But, at the moment we haven’t made much progress in the last 10 years. That said, we still kill 99% of H. pylori that is referred to us.

The Marshall Centre for Infectious Diseases Research and Training has a principle goal in facilitating the development of new vaccines for H. pylori. Given that the bacterium is part of the normal flora as you mentioned before, for approximately 50% of people, do you believe that non-pathogenic H. pylori should be eradicated?

This is the question that I had trouble with. So, statistically it is normal because half the people in the world have it, so they’re not at the two standard deviations from the mean to have H. pylori. However, it is a pathogen even in the normal flora. It’s been normal in stone age Man, ever since humans left Africa 70,000 years ago they’ve been carrying H. pylori – maybe even hundreds of thousands of years before that. So in that respect, you could say it is normal flora and it may have had a beneficial effect. The ones that get the press are due to the fact that it downregulates the immune system a little. The beauty of this might be that if you had H. pylori you were less allergic and everybody’s a little bit allergic so that’s okay. But there are these kids that are outliers in their allergy response who are way up high in their responsiveness. They’re the ones that get anaphylaxis. So maybe if you had H. pylori, you would be less likely to be up in that group, you’d be more down in the middle of the range. As humans migrated out of Africa and visited all these other continents, with different plants and animals, it’s possible that having H. pylori was a bit beneficial. You’re hiding in the bushes from a lion, all of a sudden you start sneezing, that would not be good. Being less allergic might have helped human migrations.

Nowadays, Helicobacter has been disappearing by about 50% every generation in the last 50 years. So since about 1960, in Western countries it’s just been declining. It’s not antibiotics. It’s better hygiene, smaller families and it’s not terribly infectious. If you have both parents infected, each child has about a 50% chance of picking it up from an Australian parent. It’s in the next generation, but not a lot. So you can’t blame me if Helicobacter disappears. I’m killing it, I’m doing my best, but in fact 90% of the work is just done by modern living in 21st century life.

Are there any other medical issues that you would like to see gaining the same attention as the microbiome?

I think the immune system of the gut is important. We can put things into the stomach and into the colon, but the small intestine we can’t really investigate. As far as I’m concerned, there’s only two causes of anything: genetic and environmental, in particular all the viruses that you catch in the first few years of life. I think we’ve got a long way to go but we are on the threshold of cheap sequencing. So what we’re going to see is a lot of cheap sequencing during the lifetimes of lots of people. Then maybe 10 years from now, we will have computers big enough to figure out what it all means. We will probably be able to see that a lot of it is viral triggers – who knows.

B was leaving Singapore that weekend, heading home to Bangladesh. His workplace injury compensation case had finally been resolved. We asked if he was excited for the reunion with his family after so many years abroad, and the subdued acceptance in his sad smile—“[I’m a] little bit happy”—was striking. B had fallen from scaffolding and severely injured his back, leaving him unfit for further work. Under the orders of his employer he spent months bouncing between various hospitals and clinics, looking for the “cheapest rates”. His eventual injury compensation fell far short ofhis entitlement. Ongoing disputes with his employer about his injury compensation culminated with a heated argument during which B was struck in the face. His search for help had brought him to HealthServe, and it was there he was generous enough to share his story.

It is a story that would resonate with the experiences of many low-wage migrant workers in Singapore. A review conducted by the Ministry of Manpower (MOM) in June 2017 found migrant workers account for a 37.9% of the Singaporean labour force.[1] More than half are employed as low-wage labour or in service industries.[1] Despite serving as the cornerstone for Singapore’s booming economic and architectural development, B and his fellow low-wage migrant workers constitute an especially vulnerable population,[2,3] subject to exploitation and often left shouldering significant burdens of illness and injury.

HealthServe is a not-for-profit, non-government organisation that reaches out to a community whom its small staff and indispensable volunteers pointedly refer to as their “migrant brothers and sisters”. Dr Goh Wei-Leong founded HealthServe in 2006, offering migrant workers medical care, social assistance, casework, personal development classes, and a hub for communal recreation. The 2017 Singaporean of the Year title awarded to Dr Goh (and the HealthServe organisation as a whole) has fuelled the long waiting list of medical students keen to assist with its operations.[4] We were fortunate to complete our 6-week internship at HealthServe over the recent summer university vacation.

Working at the clinic

HealthServe began as a clinic in Singapore’s Geylang district providing general practice (GP) and dental services two evenings a week and Saturday afternoons. It has since expanded to include regular specialist dermatology and orthopaedic consulting and two additional worker-dormitory-based clinics offering similar healthcare services.

As interns, clinic days meant arriving 3 hours ahead of advertised opening times to prepare for the imminent rush. Migrant brothers and sisters would come in throngs—busy days, with more than 50 patients waiting before even the first had been seen, necessitated the emotionally draining process of turning some away. HealthServe saw patients from a range of occupational backgrounds. Although most of the patients were men, staff also assisted the occasional female domestic worker referred from the Humanitarian Organisation for Migration Economics (HOME).

The clinics themselves were unlike anything we had experienced. Every role relied on volunteers, from doctors to receptionists. The clinic manager helped interns fill staffing gaps as needed, becoming temporary dental assistants, receptionists, triage ‘nurses’ and medication packers. We soon learnt that even the seemingly menial jobs played pivotal roles in the clinic’s operations, underlining the importance of an effective multidisciplinary team in delivering quality patient care.

Resources were scarce. It was eye-opening to witness how the clinic’s financial dependence on grants and donations impacted healthcare. Proton pump inhibitors were often replaced with H2 antagonists. Measuring tapes substituted for height charts. ECG machines left over from the 1990s tested our abilities to adapt and make do. We embraced the challenge.

We were soon eagerly conversing with the migrant brothers as we triaged the waiting patients, finding joy in the supposedly mundane vitals measurements. They had many stories to tell—of Bangladesh’s six seasons in a year, of the food back home in China, or of their dreams and aspirations. Triaging was an opportunity to exercise our clinical judgment supported by the safety net of the clinical manager’s review. The conversations that unfolded while doing so were potent reminders of the individuals behind the pathological processes it was so easy to become absorbed in. As Sir William Osler once said, “The good physician treats the disease; the great physician treats the patient who has the disease.”[5]

Chronic conditions like diabetes and hypertension were rife, exacerbated by poor diets and a reluctance to seek medical attention understandable when a standard consultation could cost the equivalent of 3 days’ wages. A large proportion of our patients presented suffering from muscle strains, ligament sprains, back and soft-tissue injuries, and chronic pain—the inevitable results of gruelling 12-hour shifts 6 or 7 days a week. Patients with injuries severe enough to stop them working were stuck in a jobless and incomeless limbo between the termination of their work permits and the payment of their workplace injury compensation.[6] Our hearts went out to those who described their predicament—the perpetual uncertainty of the process, the months or even years waiting for resolution, the scheming employers intent on cutting costs, and the meagre compensation eventually received.

Beyond the clinic

The inherent precarity of migrant worker life discourages outspoken resistance against exploitation for fear of pay cuts and retrenchments. Movement restrictions, squalid housing conditions, and passport confiscations are alarmingly common practices.[7,8] In 2014, one manager was jailed after pleading guilty to breaching employment regulations and underpaying wages.[9] But the enforcement of accountability is rare. Many workers arrive already in debt from the 6000 to 15,000 Singaporean dollar employment agency fees paid to secure positions before departing their home countries, leaving some convinced “it’s better to be underpaid than not paid at all.”[10]

Dr Goh, a strong proponent of learning through immersion, would encourage interns to explore migrant worker haunts, travel to dormitories, and encounter the plight of the migrant workers firsthand. We visited some of HealthServe’s dormitory-based clinics and were taken aback. The fencing erected following the 2013 ‘Little India’ riot was reminiscent of a penal institution. A dormitory floor housed 20 rooms, each shared by 8 to 10 migrant brothers. Washing machines and refrigerators were bought by the workers themselves and every floor contained one communal bathroom. The migrant brothers’ days were strictly regimented— waking up at 5:00 AM, taking the shuttle bus to work, and then returning to the dormitories to cook, bathe and sleep.

Referrals

On days when the clinic did not open, our intern responsibilities included everything from sorting medications and autoclaving dental instruments to organising the specialist referrals some migrant brother patients required. These pro bono specialist consultations relied on the goodwill and altruism of Dr Goh’s friends and colleagues who share his outlook on migrant worker health. We would accompany the migrant brothers during these appointments to alleviate their anxiety and offer emotional support. Cases we witnessed ranged from foreign body removal to the diagnosis of kidney stones secondary to horseshoe kidneys (ren arcuatus or renal fusion). Diagnostic reasoning and management plans were tailored to a population so different from the Australian and primarily Caucasian patients we had dealt with in medical school. The social determinants of a patient’s health were a factor in every decision about appropriate treatment options. No matter the outcome, the migrant workers showed gratitude towards their treating doctors and were generous in expressing appreciation towards us for accompanying them to the clinics.

Behind closed doors

Every Thursday afternoon, the staff gather for a lunch meeting at the heart of Little India. As food and laughter are shared, ideas on improving the services supporting the low-wage migrant worker community are exchanged with equal passion. The English lessons and computer classes now run by HealthServe volunteers are just two of the fruits of these weekly meetings. Dr Goh was always open to informal meetings with staff and interns to reflect and recalibrate.

Our experience at HealthServe was enriching to say the least. While there is much more to be done to help the migrant brothers and sisters driving Singapore’s economic progress, it is heart-warming to witness the ever-increasing awareness and support for migrant worker advocacy. Organisations such as Transient Workers Count Too (TWC2) and Migrant Workers’ Centre (MWC) are contributing to one day achieving what Dr Goh sees as his advocacy’s ultimate aim: “Our job in HealthServe is to make sure that we are out of job.”

We appreciate the time taken to read this article. Var Lock Tergo (“God bless” in Bengali).

Acknowledgements

The authors would like to thank HealthServe for providing the consent for writing this report on their experiences. The authors would also like to express their gratitude to HealthServe for the opportunities and experiences provided, and extend the same to everyone they met during their internship who together made the experience so enriching.